Bosom Buddies (Part 1)

Man boobs are the bane of the male species. Cosmetic Surgery & Beauty (CS&B) seeks professional advice on behalf of beleaguered gentlemen (PART 1). Part 1 talks about what is Gynaecomastia and who are the ideal candidates to receive this treatment. Part 2 will talk about how is the Gynaecomastia surgery performed and what can a patient expect post treatment

Dr. Somasundaram Sathappan - May 3, 12:23 PM

Gynaecomastia or ‘man boobs’ is an enlargement of the male breast tissue. A common occurrence, at least 30 percent of men can be affected in their lifetime. Gynaecomastia – though the result of multiple causative factors – is normally instigated by hormonal imbalances between oestrogen and testosterone action, or an increase in oestrogen to testosterone ratios and production. 
While male bodies are mostly made of testosterone – which encourages male sexual qualities like appearance and sexual development – they do produce low levels of oestrogen (female sex hormones). When boys undergo puberty or when older men produce less testosterone, the balance of both hormones change. As this occurs, higher levels of oestrogen cause breast tissue enlargement. This phenomenon is in fact so common that about half of adolescent boys and about two thirds of mature men experience gynaecomastia. While common, gynaecomastia can still result in anxiety and psychosocial discomfort. Apart from social ridicule and bullying, boys may even become reclusive, avoiding clothing removal or social activities altogether. This is why experts recommend early diagnostic evaluations of detailed medical histories, clinical examination, blood tests, imaging and tissue sampling. These diagnostic prerequisites not only allow individual treatment recommendations, but also rule out other concerns like male breast cancer and endocrinological conditions. Should tests prove zero underlying causes, individual treatments can range from simple reassurances and medical treatment up to surgery. In this article, we speak to a panel of Consultant Plastic and Reconstructive Surgeons as they explain why conditions arise, the differences between true and pseudo gynaecomastia, and how conditions are managed and treated. 
What is gynaecomastia?

Dr. Somasundaram Sathappan (Dr. Soma):
Gynaecomastia is enlargement of the breast tissues. It can be classified as iatrogenic (influenced by medications) or caused by hormonal imbalances during puberty. In any case, all patients are referred to endocrinologists to ensure adrenal glands and testes are functioning normally, as some patients may produce or have insufficient hormones. Gynaecomastia is generally triggered by hormonal imbalances, which increases breast tissue sizes. Gynaecomastia treatments can only be recommended after diagnostics prove conditions aren’t due to endocrinological origins.
Because gynaecomastia begins at puberty, patients may become emotionally distraught around the ages of 15 or older. This is mainly the result of not being able to remove clothing. Moreover, teenagers usually become the butt of endless ridicule, which inadvertently forces patients to hunch over and wear loose heavy clothing. Should bullying continue, boys may avoid social events altogether, becoming introverted recluses. From a professional standpoint, gynaecomastia – unlike other cosmetic procedures – must be resolved early to avoid prolonged emotional distress.

Dr. Yap Lok Huei (Dr. Yap): True gynaecomastia is enlargements of the male breast tissue of more than 0.5cm in diameter. When indications arise, the one concern that needs ruling out is the presence of male breast cancer. Gynaecomastia is instigated by multiple factors. These may include endocrine disorders, medications such as antacids, antibiotics and antihypertensives, testicular conditions, and even topical treatments such as tea tree oil. or lavender oil. Other common causes include hormonal changes and normal ageing. If patients have drug or puberty-influenced gynaecomastia, surgery may not be needed. Nonetheless, routine investigations including ultrasound scans, blood hormonal profiles, endocrinological and paediatric advice are useful to help differentiate these conditions. Although gynaecomastia surgery may not be required in all patients, treatment is a consideration, as breasts are associated with female sexuality and femininity. While stronger, wider and anterior-facing chests are deemed masculine, tubular projections around the nipple are considered feminine.

Dr. Dilip Gahankari (Dr. Dilip): Gynaecomastia literally means male breast tissue enlargement. It appears as a firm, rubbery mass which occurs underneath the nipple and in the central breast. A benign lump, it may similarly co-exist with excess fat tissue as well.
   Various medical reasons are known to cause ‘man boobs’. However, the most common cause in young adults is failure of early childhood or teenage breasts to naturally resolve. When gynaecomastia persists for no apparent reason, young teens often get teased at school, making patients self-conscious. This can affect sporting activities – especially swimming and surfing – or even their academic achievements.
   Gynaecomastia surgery is not usually advocated until boys are 18 years old. There are however exceptions when treating doctors believe that kids are psychologically affected by the condition, or if it is affecting their sporting career. In these circumstances, patients below ages 18 are welcome to seek specialist plastic surgeon’s advice. In Australia, Queensland State law prohibits surgeries of cosmetic intent under the age of 18. Therefore, most plastic surgeons, including myself, would seek psychologist’s or psychiatrist’s advice and ‘green light’ (recommendation) before offering any form of cosmetic surgery. Current AHPRA guidelines in Australia also indicate a minimum three-month waiting or ‘cooling off’ period between the consultation and surgery for all minors (under the age of 18) needing cosmetic procedures for medical reasons. This allows minors to have extended thinking time before undergoing any procedure of cosmetic intent.
   When tissues do not naturally resolve, other causes for gynaecomastia involve hormonal alterations caused by oversupplies of testosterone, growth hormones and other hormones naturally produced by the pituitary gland. It’s also associated with tumours and kidney, liver and testicular disorders – as these problems possibly alter normal hormonal imbalances in the body. Among mature adults, gynaecomastia can be influenced by drugs like anabolic steroids, testosterone or other hormones, certain supplements, recreational or prescription drugs and notably, some anti-epileptics as well. Although gynaecomastia patients are clinically examined to rule to out malignancy, gynaecomastia in itself does not indicate the presence of cancer.

What is pseudo gynaecomastia?

Dr. Yap:
Pseudo gynaecomastia is a different condition which comprises mainly fatty deposits, and is normally the result of weight gain, or may be secondary to hormonal changes. After ruling out associated medical and/or primary breast conditions, treatment may be offered depending on whether there is associated weight gain. If indications are due to obesity, treatment may be commenced with dietary management. In general, gynaecomastia management relies heavily on individual assessment. A part of this unique examination is tissue measurement – from small, female-like to large. Patients with mild levels of tissue excess can begin with conservative solutions like diet and exercise. I also advocate upper body exercises to build upper chests in order to help approximate a masculine chest appearance.

Dr. Dilip: True and pseudo gynaecomastia can be differentiated with a ‘pinch test’. In normal males, glandular breast tissue is present in small amounts. If the pinch test demonstrates more than 0.5cm of fibrous breast tissue, diagnosis of true gynaecomastia is made. It is then further graded into mild, moderate or severe types based on existing tissue amounts and associated excess skin.  If the entire breast feels uniform, without a firm mass beneath the nipple, then diagnosis may prove pseudo gynaecomastia. 

Who are the ideal candidates for gynaecomastia surgery?

Dr. Soma:
As Dr. Yap and Dr. Dilip have noted, gynaecomastia is divided into three grades. Grade 1 signifies a slight enlargement. Grade 2 is a moderate enlargement. Grade 3 is when there is enlargement with sagging. Any grade of gynaecomastia can be treated as long as there are indications that it affects a child or man’s mental health. Whether breast enlargements are caused by fatty deposits or breast tissue growth, every patient is appropriate for surgery as long as symptoms instigate negative emotional impacts.

Dr. Yap: Incidences of true gynaecomastia can be as common as 60 to 70 percent of young individuals undergoing puberty. In my practice, I usually agree to treatment when patients are in their late teens, as long as they’re healthy without underlying health or hormonal problems. If patients are young, I may recommend holding off treatment as teens and pre-teens are generally hormone-sensitive, meaning their bodies eventually normalise, and breasts resolve organically. If older patients present with pseudo gynaecomastia, I may or may not recommend weight loss before surgical treatment – depending on individual needs. For example, some patients have difficulty losing weight while others are happy with their sizes but desire flatter chests. Among these individuals, I advocate liposuction, as it’s highly effective in fat removal, including some breast tissue extraction. 
Dr. Dilip: Patients seeking gynaecomastia surgery should be young and healthy – without any major hormonal or organic (liver, kidney, brain, etc.) disorders. As this is an elective procedure with cosmetic intent, optimal health and fitness is advised. Should individuals desire successful surgeries with fewer risks and complications, I advise smoking cessation, weight loss to ideal BMI ranges of 21-25 and discontinuation of herbal or nutritional supplements, drugs and hormonal injections for at least four weeks prior to surgery. 
Part 2 will talk about how is a Gynaecomastia surgery performed and what can a patient expect post treatment 

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Man boobs are the bane of the male species. Cosmetic Surgery & Beauty seeks professional advice on behalf of beleaguered gentlemen. (Part 2)